Friday, July 10, 2015

Human healthcare vs veterinary care: insights from a veterinary cancer surgeon diagnosed with cancer

Have you ever had the same condition your companion animal has suffered from? As a vet I see it commonly – we diagnose the animal with something, only for the owner to say “I’m being treated for that too” or “I had that” or “my husband just got diagnosed with that”.

Usually it’s a coincidence, occasionally it’s a causal relationship (for example, some types of ringworm – a fungus not a worm – spread between humans and animals), and other times we suspect some common environmental exposure, for example to a carcinogen if the person and animal both suffer from a similar cancer. We don’t know enough in most cases to prove a relationship but is possible.

The thing is, you can have the same condition as your dog (or cat), but we treat members of different species VERY differently. Canadian veterinary surgical oncologist Dr SarahBoston learned this first-hand when she diagnosed herself with a thyroid carcinoma. Her book is a must-read.

Yes, she made the diagnosis. She has seen every animal tumour under the sun, which is why when a mass popped up on her own thyroid she knew exactly what it was. Which was devastating for her, but put her in a very unique position to compare the human and animal health care systems. And quite often animal healthcare was superior.

Her insights are brilliant. She points out the deficiencies of the human healthcare system, from enormous waiting times to communication breakdown and failure to achieve a holistic assessment of the patient. Take the diagnosis itself. Dr Boston has performed an ultrasound which she takes to her doctor.
“I hand him the USB key and ask him if he would like to look at it with me. He says that it is probably not necessary because I obviously still need an ultrasound with a radiologist. I realize that it is likely my doctor has never seen an ultrasound of a thyroid gland, except perhaps in medical school, so looking at these images will be somewhat meaningless. Human general practitioners (GPs) do not have the luxury of following their patients through their diagnostic tests, like I do. In my world I can watch the ultrasound, go over the CT scan with the radiologist, take the patient to surgery, and look at the histopathology…with the pathologist. In my GP’s world, imaging, biopsies and bloodwork are reduced to a black and white report with a bottom line from a pathologist or radiologist. The initial doctor will never get a sense of what the mass looks like.”p11-12
This is not a nasty dig. It’s an observation about the increased specialization and effective atomisation of human healthcare.
“And this is why I wish I were a dog. Because I would take better care of me. I have clients who tell me this all the time. They say that if they get sick, they want to check themselves in to our animal hospital, because the care is so much better, so much faster, and we care so much more. It’s a joke. Sort of. I will spend the next year dividing my time between having and treating cancer, between being the doctor and being the patient. It’s a perspective I would never have asked for, and I don’t mean to be critical but, well, I just can’t help myself. I’m a little critical of the human system. We need to do better. We need to care more. We need to advocate more. We need to cherish ourselves the way we do our most perfect companions – our dogs.”p14-15.
But this book also describes Dr Boston’s management of her own cases, many of which involve tumours that owners and/or veterinarians did not think could be cured or managed with surgery. As a veterinary reader, this book is worth a read just for these case histories alone. It’s a reminder of the impact of a pet’s cancer diagnosis on the owner as well as the animal but also a reminder about what can be done. And it doesn’t shy away from the bigger philosophical questions about whether we should even treat cancer in companion animals.

“If you are a dog with a mass or lump that someone thinks is cancer, your path to diagnosis and treatment will be very different than mine, with one glaringly obvious similarity: every patient needs an advocate.
…As a dog, your fate will depend on several factors, none of which you will have any control over or could possibly understand. The first factor is whether or not your family veterinarian thinks you have cancer. This could be good or bad for you. If your family veterinarian thinks you have cancer, but also has a personal belief that most cancers in animals are not treatable and that dogs do not do well with aggressive cancer treatment, the spin they put on your presumptive diagnosis will not be good. In these cases, only the most persistent clients will reject the idea that their dog is old and probably has had cancer and the most sensible and humane thing to do would be to let them go – and soon. If your vet thinks you have cancer, and gets on it with a good diagnostic plan and a referral to a specialist to discuss the options, you have a chance. If your vet missed the fact that you might have cancer altogether, then precious time will have been wasted on symptomatic treatments that will not improve your situation.The second factor is your owner. Did they notice that something was wrong with you and take you to a doctor in the first place?
Money is also a major factor. All the tests and procedures cost money. Your veterinarian needs to know what to recommend and how to explain the value of these tests to your owner. Your owner needs to understand the recommendations, and want to move forward, and be able to afford care. Where you fit into your household is also important. Are you a four-legged, furry child? Do you sleep in the same bed as your owner? If you have never achieved this status, or if you have lost it because of the appearance of real, two-legged, fur-less children, things may not go well for you. Your owner’s opinion of cancer and previous experiences with this disease will also play a role. Many clients will say, “If it’s cancer, I don’t want to treat,” or “If it’s cancer, there’s nothing we can do about it anyway,”, not realizing that some cancers are more treatable than many chronic health problems. If you are a dog, your whole life hangs in the balance of perception.”p119-120.
“Sometimes just the word cancer, and not the disease itself, is enough to bring a dog’s life to an end, even if it is a suggestion and not a firm diagnosis. A dog’s life is only as important as we think it is, and it is only worth as much as we can afford, or choose, to pay. A dog’s death is only as sad as it makes the owners who loved him, and a dog’s recovery from cancer or fake cancer is only as happy as it makes the people who are cheering him on.”p125
Her story is well worth reading for anyone who works in human healthcare, animal healthcare, or anyone interested in the different ways we treat human and animal cancer patients.  It is a very easy read while simultaneously providing insight into the management of complicated cases. This is one of the most interesting veterinary biographies I’ve ever read and certainly the only one that tackles the human vs animal healthcare systems head-on, with humour that many would struggle to muster in such a situation. Once I started I could not stop reading it.